Dental health of children with cerebral palsy
Basil M. Jan, dental student, Mohammed M. Jan, MB.Ch.B, FRCP(C).
ABSTRACT
‫يعتبر الشلل الدماغي من األمراض العصبية الشائعة واملصحوبة‬
‫ ويعتبر‬.‫بصعوبات باملهارات الذهنية والتواصل والتشنجات العصبية‬
‫األطفال املصابني بالشلل الدماغي أكثر عرضه للمشاكل بصحة األسنان‬
‫ لذا وجب‬.‫مما يؤثر سلب ًا علي صحتهم العامه ونوعية حياتهم اليومية‬
‫إدراج فحص األسنان ضمن التقييم االولي جلميع االطفال املصابني‬
‫ الهدف من هذا املقال هو تقدمي مراجعة حديثة‬.‫بالشلل الدماغي‬
‫وشاملة عن صحة األسنان لدى األطفال املصابني بالشلل الدماغي‬
‫ مع العلم أن‬.‫وتوضيح أهم االستراجيات الوقائية والعملية للعالج‬
‫تقدمي العناية الالزمة للفم يحتاج استخدام مهاراة خاصة ملساعدة‬
‫ مع‬.‫الوالدين علي االهتمام بأي مشاكل محتمل حدوثها لالسنان‬
‫العلم أن صحة الفم يتم اعتبارها اآلن بصورة متزايدة بأنها من أساسيات‬
‫الصحة العامة لذا فأن املهتمني مبرضى الشلل الدماغي يجب اعتبارهم‬
‫من أهم مكونات فريق العناية بصحة الفم وبالتالي وجب عليهم أن‬
‫يكونون علي قدر من العلم و الكفائة بالقيام باالشراف على صحة‬
.‫الفم باملنزل‬
Cerebral palsy (CP) is a common chronic motor
disorder with associated cognitive, communicative,
and seizure disorders. Children with CP have a
higher risk of dental problems creating significant
morbidity that can further affect their wellbeing and
negatively impact their quality of life. Screening for
dental disease should be part of the initial assessment
of any child with CP. The objective of this article is to
present an updated overview of dental health issues in
children with CP and outline important preventative
and practical strategies to the management of this
common comorbidity. Providing adequate oral care
requires adaptation of special dental skills to help
families manage the ongoing health issues that may
arise. As oral health is increasingly recognized as
a foundation for general wellbeing, caregivers for
CP patients should be considered an important
component of the oral health team and must become
knowledgeable and competent in home oral health
practices.
Neurosciences 2016; Vol. 21 (4): 314-318
doi: 10.17712/nsj.2016.4.20150729
From the Department of Pediatrics, Faculty of Medicine, King
Abdulaziz University, Jeddah, Kingdom of Saudi Arabia
314 Neurosciences 2016; Vol. 21 (4)
Address correspondence and reprint request to: Prof. Mohammed M.
Jan, Department of Pediatrics, Faculty of Medicine, King Abdulaziz
University, Jeddah, Kingdom of Saudi Arabia. Tel. +996 12 6401000
Ext. 20208. E-mail: mmjan@kau.edu.sa
C erebral palsy (CP) is a common pediatric disorder
occurring in approximately 2-2.5 per 1000 live
births.1 It is a chronic motor disorder resulting from
a non-progressive (static) insult to the developing
brain.2 The motor disorders associated with CP are
often accompanied by disturbances in coordination,
cognition, communication, and seizure disorders.3,4
Children with CP are at increased risk of developing
dental problems as compared with healthy controls.5
This can create significant morbidity that can further
affect the wellbeing of these compromised children and
negatively impact their quality of life.6 Screening for
these conditions should be part of the initial assessment.
The objectives of this article are to present an updated
overview of dental health issues in children with CP and
outline important preventative and practical strategies
to the management of this common comorbidity.
Predisposition to dental disease in CP. Studies have
shown that the more severe the neurological insult
in children with CP, the higher is the risk of dental
disease.7,8 This results from multiple factors including
motor and coordination difficulties, as well as limited
oral care and hygiene. Various possible predisposing
factors are summarized in Table 1. These include
mental retardation, which is more common in children
with severe CP particularly in those with epilepsy or
cortical abnormalities on neuroimaging.9 Children with
mental retardation are dependent on their caregiver
for maintaining oral and dental hygiene making
them at higher risk for dental disease. In addition,
approximately 30% of CP patients are undernourished,
Disclosure. The authors declare no conflicting interests,
support or funding from any drug company.
OPEN ACCESS www.neurosciencesjournal.org
 Dental health in cerebral palsy … Jan B & Jan M
Table 1 - Factors possibly predisposing to dental disease in children with cerebral palsy.
Predisposing factors
Motor weakness or incoordination
Mental retardation
Pseudo-bulbar palsy
Gastroesophageal reflux disease
Malnutrition
affecting their dental health.10 The leading cause of
poor nutrition appears to be pseudo-bulbar palsy,
affecting the coordination of sucking, chewing, and
swallowing. Excessive drooling (sialorrhea) also results
from pseudo-bulbar palsy, however, it may also be
related to increased production of saliva secondary to an
irritating oral lesion, such as dental caries or infection.11
In addition, gastroesophageal reflux disease (GERD) is
another common problem in children with CP causing
regurgitation, vomiting, and possible aspiration.12 The
GERD affects the dental health and results in dental
erosions.13
Specific dental manifestations: Dental Caries. In
general, many factors contribute to the development of
dental caries including biological, economic, cultural,
environmental and social factors.14 Patients with CP are
at increased risk of developing dental caries affecting
negatively their quality of life.15 Children with more
severe neurological insult are at a greater the risk.16
The degree of cognitive and motor deficits is directly
proportional to the likelihood of developing dental
caries.17 Severe motor incoordination affects the ability
to perform adequate oral hygiene and cognitive deficits
makes cooperation for effective oral care more difficult.18
Periodontal disease. Several studies have shown
that gingival hyperplasia and associated bleeding
occurs with higher frequency in children with CP.19,20
This high frequency may be due to the same factors
predisposing to dental caries and leading to biofilm
buildup.21 Difficulties in conducting daily oral hygiene,
intraoral sensitivity, and oro-facial motor dysfunction
are the main contributing factors.22 Another important
factor is the use of antiepileptic drugs, particularly
phenytoin.23 Gingival hyperplasia is predictive for
periodontal diseases. It tends to occur in children with
spastic quadriplegic CP, particularly with advancing
age. Choreothetoid CP may also be associated with
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Mechanism
Inability to maintain oral hygiene
Depending on a caregiver for self care risk of dental trauma
Inability to maintain oral hygiene
Depending on a caregiver for self care
Chewing and swallowing difficulties
Risk of dental caries and erosions
Excessive drooling (sialorrhea)
Recurrent regurgitation and vomiting causing dental erosions
Poor calcium intake
Vitamin D deficiency
periodontal disease as a result of the continuous
uncontrolled movements of the head making oral
hygiene more difficult.24
Dental erosion. Dental erosion is a progressive loss
of hard dental tissue resulting from a chemical (non-
bacterial) process.25 Gastroesophageal reflux disease is
the single most important cause of dental erosions noted
in up to 55% of patients.26 In one study, 75% of children
with reflux on a 24-hour esophageal pH monitoring had
moderate to severe erosion.27 Dental erosion is common
in patients with CP who are predisposed to GERD.
Another study found 73% of CP patients with dental
erosions had history of GERD.28 Swallowing difficulties
and recurrent chest infections were associated with
the development of dental erosion in another study.29
Enamel erosion that affects the posterior dentition may
be the first indication of GERD. However, both primary
and permanent teeth can be affected, most commonly
the upper molars, lower molars and upper incisors.
Continuous chemical exposure may gradually result
in the extension of the dental erosions. Early effective
treatment of GERD is critical to avoid irreversible
dental damage.30 Prevention, early identification, and
intervention are needed to prevent permanent damage.
Sialorrhea. Drooling of saliva (sialorrhea) appears
to be the consequence of a dysfunction in the
coordination of swallowing mechanisms (pseudo-
bulbar palsy) and mouth opening. Drooling is not
socially accepted and can produce significant negative
effects on the psychosocial health and quality of life.31 It
occurs in up to 30% of children with CP.32 Sometimes
drooling is related to an irritating lesion, such as
dental caries or throat infection, resulting in increased
production of saliva. Severe drooling may get worse
with some antiepileptic drugs, such as clonazepam,
leading to aspiration syndrome, skin irritation, and
articulation difficulties.32 Management of this difficult
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 Dental health in cerebral palsy … Jan B & Jan M
problem is not very effective and includes a trial of an
anticholinergic medication, such as glycopyrrolate and
scopolamine. Side effects include irritability, sedation,
blurred vision, and constipation.33 Scopolamine is also
available as a skin patch. Surgical re-routing of salivary
ducts is an option, however, it may lead to increased
aspiration.33 Botulinum toxin injection into the parotid
and submandibular glands may be effective in reducing
excessive drooling.34
Bruxism. Bruxism, the habitual grinding of teeth,
is a common problem in children with CP, particularly
those with severe motor and cognitive deficits.35
Bruxism may lead to teeth abrasion and flattening
of biting surfaces. The exact mechanisms causing
the development of this habit is not fully known,
however, it is likely a self-stimulatory behavior and
could also be related to abnormal proprioception in
the periodontium.36 It is known that children with CP
are predisposed to such abnormal behaviors including
finger sucking and other mouthing habits. Local dental
factors, such as malocclusion, should be excluded. As
well, sleep disorders may predispose to the development
of nocturnal bruxism, particularly in those with severe
visual impairment.37 Disturbed and fragmented sleep
is very disruptive to the parents as a result of frequent
nocturnal awakenings. Medications that improve the
sleep-wake cycle, such as melatonin, should be used and
may also result in improved daytime behavior.37
Traumatic dental injuries. Motor deficits and
epilepsy increase the risk of physical injuries in children
with CP. Malocclusion with prominent maxillary
incisors and incompetent lips represent local risks that
further predisposing to dental trauma.38 The risk varies
between 10-20% and can reach 60% in patients with
drop attacks.39 In addition to facial injury, these children
are predisposed to fracture of enamel and dentine.40
Malocclusion. Malocclusion has been reported
with increasing frequency in children with CP, most
commonly over-bite and anterior open-bite.41 These
abnormalities have been reported to get worse with
age.42 Mouth breathing, lip incompetence and long
face are contributing factors.43 Pseudo-bulbar palsy,
oro-facial incoordination and hypotonia could further
add to the risk of developing malocclusion.
Enamel defects. Children with CP are at an increased
risk for having developmental enamel defects.44 Around
40% of affected children were born prematurely
(<37 weeks). These enamel defects are located in a
symmetrical manner in both primary incisors and first
molars.
316 Neurosciences 2016; Vol. 21 (4)
Temporomandibular joint (TMJ) disorders. Children
with CP are at a significantly higher risk for developing
signs and symptoms of TMJ disorders.45 Male gender,
the presence and severity of any malocclusion, mouth
breathing, and mixed dentition were all identified as
risk factors for developing signs and symptoms of TMJ
disorders in CP patients.
Dental management. Some practical challenges are
commonly encountered when handling children with
CP. These include apprehension, fear from strangers, and
communication difficulties.46 Effective communication
with such children during dental assessment should
take in consideration their developmental age and any
associated auditory, visual or speech disorders. Cognitive
and attention deficits can also contribute to cooperation
difficulties. Special seating and positioning adjustments
are needed for children with abnormal posture. The
dental chair should allow careful adjustment to provide
the needed stability and support. Tipping the chair well
back is often needed in spastic and athetoid CP patients
with more manual control. Supportive and relaxed
approach can help in improving the child’s cooperation.46
A useful tip is to schedule the visit early in the day and
allow sufficient time to establish appropriate interaction
during such encounters.47 The dentist may not establish
much during the first visit that may be used mainly to
establish mutual confidence and have a preliminary
assessment. Assistance from the parents and dental
assistant is often needed particularly for immobilization
and during X-ray procedures. Patients with more severe
spasticity involving the head and neck may be best
evaluated on the parent’s lap.48 Head position can be
also maintained in the midline by the help of Velcro
straps. Open mouth can be maintained with the use of
mouth props and the dentist should try their best to be
gentle, caring, and avoid sudden movements that may
trigger muscle spasm or stiffening. A finger guard and a
steel mirror are preferred to avoid injury or shattering.
Sharp instruments should be used with extreme caution
to prevent injury. There are no reservations on using
local anesthesia. CP patients often have difficulty rinsing
appropriately necessitating the provision of water spray
and suction device. Orthodontic or prosthetic parts are
advisable only if the disability is mild to minimize the
risk of breakage and aspiration.
Sedation & anesthesia. Children with CP may be
difficult to handle and uncooperative during dental
assessment and management. Sedation and anesthesia
is frequently needed in such situations, particularly if
invasive procedures are needed.49 History of respiratory
difficulties and seizures represent a particular challenge.
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 Dental health in cerebral palsy … Jan B & Jan M
Assessment by the concerned specialty (pediatrics,
anesthesia, and/or neurology) is often needed prior to the
required procedure. If the procedure is associated with
prolonged period of decreased oral intake, intravenous
antiepileptic drugs can replace the oral medications.
Drugs like phenobarbitone or phenytoin can be used,
however, a loading dose should be initiated before the
procedure for optimal effects.50 Once the patient is able
to take the oral drugs, IV drugs can be weaned quickly.
Many drugs can be used to induce sedation and
anesthesia including benzodiazepines, nitrous oxide,
narcotics, and propofol.51 Most children with CP and
severe mental disability do not tolerate initial facemask
prior to IV sedation. However, nasal or facemask can
be utilized in milder cases to avoid the fear and anxiety
associated with IV insertion. Oxygen saturation should
be monitored by pulse oximetry and the airway should
be protected throughout the procedure. Children
with CP are at an increased risk of aspirating dental
filling materials, debris from preparation of the tooth,
or even an extracted tooth. This is in addition to
excessive salivation and water spray used for cooling
instruments.51 A throat shield should always be used to
further protect the airway in these cases. Postoperative
care include keeping the child with CP restrained until
he or she is able to respond to verbal commands or
become fully consciousness. IV cannulas and monitor
should be removed as soon as possible as they add to the
child’s fear and anxiety. Most patients with CP tolerate
such procedures and sedation well with minimal
postoperative complications.52
Prevention. Home dental care and hygiene should
be promoted from early on. Parents should learn to start
gently daily cleansing of the incisors with a soft cloth or
an infant soft toothbrush. For older children who are
unwilling or physically unable to cooperate, the dentist
should teach the parent proper brushing techniques
and ways to safely restrain the child when necessary.
The child is placed in the parent’s lap to stabilized the
head with one hand while using the other hand to brush
the teeth. An older child may recline on a chair or bed
and the parent angles the head backward with one hand
while the teeth are brushed with the other hand. More
extreme restraining by both parents is needed for the
more difficult child.53 The patient’s hands may have to
be restrained by a second or third person for effective
oral cleansing.53 To encourage independence of children
with milder motor disabilities, an electric toothbrush
may be utilized effectively.
In conclusions, as oral health is increasingly
recognized as a foundation for general wellbeing,
www.neurosciencesjournal.org
caregivers for CP patients should be considered an
important component of the oral health team and must
become knowledgeable and competent in home oral
health practices. Such practices can significantly affect
the child’s quality of life and control dental costs.
References
1. Bax M, Goldstein M, Rosebaum P, Leviton A, Paneth N, Dan
B, et al. Proposed definition and classification of cerebral palsy,
April 2005. Dev Med Child Neurol 2005; 47: 571-576.
2. Jan MM. Cerebral palsy: comprehensive review and update.
Ann Saudi Med 2006; 26: 123-132.
3. Rosenbaum P, Stewart D. The World Health Organization
International Classification of Functioning, Disability, and
Health: a model to guide clinical thinking, practice and research
in the field of cerebral palsy. Semin Pediatr Neurol 2004; 11:
5-15.
4. Gokkaya NK, Caliskan A, Karakus D, Ucan H. Relation
between objectively measured growth determinants and
ambulation in children with cerebral palsy. Turk J Med Sci
2009; 39: 85-90.
5. Grzić R, Bakarcić D, Prpić I, Jokić NI, Sasso A, Kovac Z, et al.
Dental health and dental care in children with cerebral palsy.
Coll Antropol 2011; 35: 761-764.
6. Sehrawat N, Marwaha M, Bansal K, Chopra R. Cerebral palsy:
a dental update. Int J Clin Ped Dent 2014; 7: 109-118.
7. Sankar C, Mundkur N. Cerebral palsy definition, classification,
etiology and early diagnosis. Indian J Pediatr 2005; 72:
865-868.
8. Jones MW, Morgan E, Shelton JE. Primary care of the child
with cerebral palsy: a review of system (Part II). J Pediatr Health
Care 2007; 21: 226-237.
9. Russman BS, Ashwal S. Evaluation of the child with cerebral
palsy. Semin Pediatr Neurol 2004; 11: 47-57.
10. Eltumi M, Sullivan PB. Nutritional management of the disabled
child: the role of percutaneous endoscopic gastrostomy. Dev
Med Child Neurol 1997; 39: 66-68.
11. Siegel L, Klingbeil M. Control of drooling with transdermal
scopolamine in a child with cerebral palsy. Dev Med Child
Neurol 1991; 33: 1013-1014.
12. Alsaggaf AH, Jan MM, Saadah OI, Alsaggaf HM. Percutaneous
endoscopic gastrostomy (PEG) tube placement in children with
neurodevelopmental disabilities: parents’ perspectives. Saudi
Med J 2013; 34: 695-700.
13. Polat Z, Akgun OM, Turan I, Polat GG, Altun C. Evaluation
of the relationship between dental erosion and scintigraphically
detected gastroesophageal reflux in patients with cerebral palsy.
Turk J Med Sci 2013; 43: 283-288.
14. Beck JD, Youngblood M Jr, Atkinson JC, Mauriello S, Kaste
LM, Badner VM, et al. The prevalence of caries and tooth loss
among participants in the Hispanic Community Health Study/
Study of Latinos. J Am Dent Assoc 2014; 145: 531-540.
15. Cardoso AM, Gomes LN, Silva CR, Soares RD, De Abreu
MH, Padilha WW, et al. Dental caries and periodontal disease
in Brazilian children and adolescents with cerebral palsy. Int J
Environ Res Public Health 2014; 12: 335-353.
16. Santos MT, Guare RO, Celiberti P, Siqueira WL. Caries
experience in individuals with cerebral palsy in relation to
oromotor dysfunction and dietary consistency. Spec Care
Dentist 2009; 29: 198-203.
Neurosciences 2016; Vol. 21 (4) 317
 Dental health in cerebral palsy … Jan B & Jan M
17. Dourado Mda R, Andrade PM, Ramos-Jorge ML, Moreira RN,
Oliveira-Ferreira F. Association between executive/attentional
functions and caries in children with cerebral palsy. Res Dev
Disabil 2013; 34: 2493-2499.
18. Subasi F, Mumcu G, Koksal L, Cimilli H, Bitlis D. Factors
affecting oral health habits among children with cerebral palsy:
pilot study. Pediatr Int 2007; 49: 853-857.
19. Minear WL. A classification of cerebral palsy. Pediatrics 1956;
18: 841-852.
20. World Health Organization. International classification
of functioning (ICF), disability and health. WHO- FIC
information sheet. Geneva (CH): WHO; 2010. Available from:
http://www.who.int/classifications/en/
21. Graham HK, Harvey A, Rodda J, Nattrass GR, Pirpiris M. The
Functional Mobility Scale (FMS). J Pediatr Orthop 2004; 24:
514-520.
22. Gunel MK, Mutlu A, Tarsuslu T, Livanelioglu A. Relationship
among the Manual Ability Classification System (MACS), the
Gross Motor Function Classification System (GMFCS), and
the functional status (WeeFIM) in children with spastic cerebral
palsy. Eur J Pediatr 2009; 168: 477-485.
23. Jan MM. Clinical review of pediatric epilepsy. Neurosciences
(Riyadh) 2005; 10: 255-264.
24. Parkin SF, Hargreaves JA, Weyman J. Children’s dentistry in
general practice. Br Dent J 1970; 129: 27-29.
25. Barron RP, Carmichael RP, Marcon MA, Sàndor GK. Dental
erosion in gastroesophageal reflux disease. J Can Dent Assoc
2003; 69: 84-89.
26. Vakil N, van Zanten SV, Kahrilas P, Dent J, Jones R; Global
Consensus Group. The Montreal definition and classification
of gastroesophageal reflux disease: a global evidence-based
consensus. Am J Gastroenterol 2006; 101: 1900-1920; quiz
1943.
27. Shaw L, Weatherill S, Smith A. Tooth wear in children: an
investigation of etiological factors in children with cerebral
palsy and gastroesophageal reflux. ASDC J Dent Child 1998;
65: 484-486.
28. Su JM, Tsamtsouris A, Laskou M. Gastroesophageal reflux
in children with cerebral palsy and its relationship to erosion
of primary and permanent teeth. J Mass Dent Soc 2003; 52:
20-24.
29. Gonçalves GK, Carmagnani FG, Corrêa MS, Duarte DA,
Santos MT. Dental erosion in cerebral palsy patients. J Dent
Child (Chic) 2008; 75: 117-120.
30. Goncalves GK, Carmagnani FG, Correa MS, Duarte DA,
Santos MT. Dental erosion in cerebral palsy patients. J Dent
Child 2008; 75: 117-120.
31. Meningaud JP, Pitak-Arnnop P, Chikhani L, Bertrand JC.
Drooling of saliva: a review of the etiology and management
options. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2006; 101: 48-57.
32. Siegel L, Klingbeil M. Control of drooling with transdermal
scopolamine in a child with cerebral palsy. Dev Med Child
Neurol 1991; 33: 1013-1014.
33. Toder D. Respiratory problems in the adolescent with
developmental delay. Adolesc Med 2000; 11: 617-631.
34. Ohito FA, Opinya GN, Wang’ombe J. Traumatic dental injuries
in normal and handicapped children in Nairobi, Kenya. East
Afr Med J 1992; 69: 680-682.
35. Ortega AOL, Guimaraes AS, Ciamponi AL, Marie SKN.
Frequency of parafunctional oral habits in patients with cerebral
palsy. J Oral Rehabil 2007; 34: 323-328.
318 Neurosciences 2016; Vol. 21 (4)
36. Lindqvist B, Heijbel J. Bruxism in children with brain damage.
Acta Odontol Scand 1974; 32: 313-319.
37. Jan MM. Melatonin for the treatment of handicapped children
with severe sleep disorders. Pediatr Neurol 2000; 23: 229-232.
38. Holan G, Peretz B, Efrat J, Shapira Y. Traumatic injuries to the
teeth in young individuals with cerebral palsy. Dent Traumatol
2005; 21: 65-69.
39. Al-Banji MH, Zahr DK, Jan MM. Lennox-Gastaut syndrome.
Management update. Neurosciences (Riyadh) 2015; 20:
207-212.
40. dos Santos MT, Souza CB. Traumatic dental injuries in
individuals with cerebral palsy. Dent Traumatol 2009; 25:
290-294.
41. Strodel BJ. The effects of spastic cerebral palsy on occlusion.
ASDC J Dent Child 1987; 54: 255-260.
42. Rosenbaum CH, McDonald RE, Levitt EE. Occlusion of
cerebral-palsied children. J Dent Res 1966; 45: 1696-1700.
43. Miamoto CB, Ramos-Jorge ML, Pereira LJ, Paiva SM, Pordeus
IA, Marques LS. Severity of malocclusion in patients with
cerebral palsy: determinant factors. Am J Orthod Dentofacial
Orthop 2010; 138: 394-395.
44. Lin X, Wu W, Zhang C, Lo EC, Chu CH, Dissanayaka WL.
Prevalence and distribution of developmental enamel defects in
children with cerebral palsy in Beijing, China. Int J Paediatr
Dent 2011; 21: 23-28.
45. Miamoto CB, Pereira LJ, Paiva SM, Pordeus IA, Ramos-Jorge
ML, Marques LS. Prevalence and risk indicators of
temporomandibular disorder signs and symptoms in a pediatric
population with spastic cerebral palsy. J Clin Pediatr Dent
2011; 35: 259-263.
46. Jan MM. Neurological examination of difficult and poorly
cooperative children. J Child Neurol 2007; 22: 1209-1213.
47. Dean JA, Avery DR, McDonald RE, editors. Dentistry for
the child and adolescents. 9th ed. Missouri (USA): Elsevier
publication; 2011.
48. Santos MT, Manzano FS. Assistive stabilization based on the
neurodevelopmental treatment approach for dental care in
individuals with cerebral palsy. Quintessence Int 2007; 38:
681-687.
49. Wongprasartsuk P, Stevens J. Cerebral palsy and anaesthesia.
Paediatr Anaesth 2002; 12: 296-303.
50. Jan MM, editor. Manual of child neurology: problem based
approach to common disorders. Bentham science: UAE; 2012.
51. Solomowitz BH. Treatment of mentally disabled patients with
intravenous sedation in a dental clinic outpatient setting. Dent
Clin North Am 2009; 53: 231-242.
52. Loyola-Rodriguez JP, Aguilera-Morelos AA, Santos-Diaz MA,
Zavala-Alonso V, Davila-Perez C, Olvera-Delgado H, et al.
Oral rehabilitation under dental general anesthesia, conscious
sedation, and conventional techniques in patients affected by
cerebral palsy. J Clin Pediatr Dent 2004; 28: 279-284.
53. Ferguson FS, Cinotti D. Home oral health practice: the
foundation for desensitization and dental care for special needs.
Dent Clin North Am 2009; 53: 375-387.
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